Wiki Electroncially signed by

[WShope0119]

Is there anybody on the discussion board that can tell me where I can find documentation stating that electronic records must say electronically signed by or can it just simply state the providers name on a study from inside the office. Any expertise help would be much appreciated.

 

[thomas7331]

I've not seen any regulation that specifically states that this wording must be used, only that the record must be authenticated by the provider and that the signature must be valid. You can find more information in this Medicare publication linked below - the electronic signature guidelines are at the bottom of page 3:

https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf

In my experience, I would find it unusual for an electronic record to have been authenticated but only have the provider's name and not say 'signed'. But the EHR should have an internal process that uses each individual provider's secure access to electronically sign and there should be a record in the system that would confirm whether or not this has taken place. If the records do not say ' electronically signed by', and your providers are saying that they have signed them, you may wish to check with your electronic health record vendor how to view the electronic audit trail to determine whether or not this is really the case. It may be that it's just printing out this way due to the way the EHR is set up, which is probably a minor issue, but on the other hand it might be that the providers are not using the EHR properly to authenticate their signature in the EHR when they close their notes. Either way, I think it would be a good idea to get it corrected so there is no question in the event that your records are audited.